Intensified Infection Control Measures Research Articles

Influence of public health and infection control interventions during the severe acute respiratory syndrome coronavirus 2 pandemic on the in-hospital epidemiology of pathogens: in hospital versus community circulating pathogens

BackgroundThe first detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Germany was reported in early February 2020. In addition, extensive control measures on the coronavirus disease 2019 (COVID-19) pandemic have been placed in Germany since March 2020. These include contact and travel restrictions, distance rules, mandatory wearing of face masks and respirators, cancellation of mass events, closures of day-care centers, schools, restaurants and shops, isolation measures, and intensified infection control measures in medical and long-term care facilities. Changes in demand or access to health care services and intensified control measures can lead to changes in transmission dynamics and imply effects on the overall occurrence of infectious diseases in hospitals.MethodsTo analyze the impact of infection control measures implemented in public on infectious diseases in hospitals, surveillance data from Marburg University Hospital were analyzed retrospectively. The analysis was conducted from January 2019 to June 2021, referred to hospital occupancy and mobility data in the county of Marburg-Biedenkopf, and correlated to control measures in hospitals and the general population.ResultsThe COVID-19 pandemic and associated measures immediately impacted the occurrence of infectious diseases at the Marburg University Hospital. Significant changes were detected for virus-associated respiratory and gastrointestinal diseases. The massive drop in norovirus infections was significantly affected by the onset of the pandemic (P = 0.028). Similar effects were observed for rotavirus (up to − 89%), respiratory syncytial virus (up to − 98%), and adenovirus infections (up to − 90%). The decrease in gastrointestinal and respiratory virus detection rates was significantly affected by the decline in mobility (P < 0.05). Of note, since April 2020, there have been no detected influenza cases. Furthermore, Clostridioides difficile-related infections declined after late 2020 (− 44%). In contrast, no significant changes were detected in the prevalence of susceptible and drug-resistant bacterial pathogens. In particular, the detection rates of methicillin-resistant Staphylococcus aureus isolates or multidrug resistant (MDR) and extended drug resistant (XDR) bacteria remained constant, although the consumption of hand disinfectants and protective equipment increased.ConclusionsThe COVID-19 pandemic and associated public health measures had a significant impact on infectious diseases and the detection of pathogens at the Marburg University Hospital. Significant changes were observed for community transmissible infections, while no such effects on pathogens primarily associated with nosocomial transmission could be detected.

Role of the environment in transmission of Gram-negative bacteria in two consecutive outbreaks in a haematology-oncology department

SummaryIn 2019–2020, two subsequent outbreaks caused by phenotypically identical ESBL-producing Enterobacter cloacae and multi-drug-resistant (MDR) Pseudomonas putida were detected in respectively 15 and 9 patients of the haematology-oncology department. Both bacterial species were resistant to piperacillin-tazobactam, used empirically in (neutropenic) sepsis in our hospital, and ciprofloxacin, used prophylactically in selective digestive decontamination for haematology patients. The E. cloacae outbreak was identified in clinical cultures of blood and urine. Despite intensified infection control measures, new cases were found in weekly point-prevalence screening cultures. Environmental samples of sinks and shower drains appeared positive in 18.1%. To diminish the environmental contamination burden, all siphons of sinks were replaced, and disinfection of sinks and shower drains was intensified using chlorine and soda on a daily basis. Replacement of shower drains was not possible. The outbreak of P. putida remained limited to rectal cultures only, and disappeared spontaneously without interventions. During both outbreaks, multiple strains of the incriminated bacterium were found simultaneously (demonstrated by Amplified-Fragment Length Polymorphism and/or Whole-Genome Multi-locus Sequencing Typing) in patients as well as the environment. It was experimentally shown that a biofilm on the toilet edge may act as a source for nosocomial transmission of Gram-negative bacteria. In conclusion, the drainage system of the hospital is an important reservoir of MDR bacteria, threatening the admitted patients. In existing hospitals, biofilms in the drainage systems cannot be removed. Therefore, it is important that in (re)building plans for hospitals a plan for prevention of nosocomial transmission from environment to patients is incorporated.

Resurgence of Respiratory Syncytial Virus Infections during COVID-19 Pandemic, Tokyo, Japan.

More than a year into the coronavirus-19 pandemic, intensified infection control measures have controlled most viral respiratory infections in Tokyo, Japan. As of July 2021, however, an unusually high number of respiratory syncytial virus infections were reported in Tokyo. This resurgence may have resulted from restarting social activities for children.

Invasive Klebsiella pneumoniae Infections in Community-Settings and Healthcare Settings.

ObjectiveTo assess clinical characteristics, outcomes and antimicrobial resistance of invasive Klebsiella pneumoniae (KP) infections in Chinese pediatric patients in hospital and community settings.MethodsThis retrospective study was conducted in the nine tertiary hospitals during 2016–2018. The 324 pediatric inpatients who had KP isolated from blood and cerebrospinal fluid and had complete medical records reviewed were included. We analyzed the risk factors, outcomes and antimicrobial resistance pattern of KP-infected patients based on comparison between healthcare-associated KP infections (HAI) and community-acquired infections.ResultsOf the 324 enrolled patients, 275 (84.9%) were clinically defined as HAI, including 175 (63.6%) neonates and 100 (36.4%) aged >28 days. The overall prevalence of CRKP was 38.2% (43.4% in HAI verse 8.7% in CAI, P <0.05). Prematurity (odds ratio (OR): 37.07, 95% CI: 8.29–165.84), hematologic malignancies (OR: 15.52, 95% CI: 1.89–127.14) and invasive mechanical ventilation (OR: 13.09, 95% CI: 1.66–103.56) were independent risk factors for HAI. Patients from rural area (OR: 1.94, 95% CI: 1.12–3.35), invasive mechanical ventilation (OR: 2.33, 95% CI: 1.25–4.33), antibiotic therapy prior to admission (OR: 2.33, 95% CI: 1.25–4.33) and prior hospital stay in the past 30 days (OR: 3.46, 95% CI: 1.87–6.41) were associated with healthcare-associated CRKP infections. Organ dysfunction was independently correlated with poor outcomes (OR: 2.92, 95% CI: 1.23–6.95).ConclusionPediatric invasive KP infections and high prevalence of CRKP infections largely occurred in healthcare settings in China. The adequate and intensified infection control measures should be focused on high-risk hematologic patients, neonatal patients and intubated patients.

Management of a Hospital-Wide COVID-19 Outbreak Affecting Patients and Healthcare Workers

To the best of our knowledge, here, we describe the first hospital-wide outbreak of SARS-CoV-2 that occurred in Germany in April 2020. We aim to share our experience in order to facilitate the management of nosocomial COVID-19 outbreaks in healthcare facilities. All patients and hospital workers were screened for SARS-CoV-2 repeatedly. An infection control team on the side was installed. Strict spatial separation of patients and intensified hygiene training of healthcare workers (HCW) were initiated. By the time of reporting, 26 patients and 21 hospital workers were infected with a cluster of cases in the geriatric department. Fourteen patients developed COVID-19 consistent symptoms and five patients with severe pre-existing medical conditions died. The outbreak was successfully contained after intensified infection control measures were implemented and no further cases among patients were detected over a period of 14 days. Strict application of standard infection control measures proved to be successful in the management of nosocomial SARS-CoV-2 outbreaks.

COPING WITH THE COVID19 PANDEMIC IN A HEMATOLOGY, TRANSPLANTATION AND CELL THERAPY UNIT IN SOUTHERN BRAZlL

We started 2020 with perspectives that quickly changed in March when the SARS-Cov-2 pandemic started in Brazil. Our center has a unit, called the Protected Environment with 30 beds with HEPA filters where malignant disease, autologous and allogeneic transplants are performed. In March 2020, the contingency plan designed since January to deal with COVID 19 pandemic of Porto Alegre Clinicas Hospital (HCPA) began highly restricting visits, consultations and elective procedures.&#x0D; Our challenge was to maintain the best care for our patients and healthcare professional’s safety. We suspend all visits and reduce relative patients’ companies to only essential. Our team was already one with the highest percentage of hand washing in the hospital, intensified infection control measures and implemented new individual protection equipment surgical masks and face shields. We started a new way to inform family members using digital platforms and improved the Wi-Fi network inside the unit to maintain patient external contact and reduce their loneliness. All Professional meetings and rounds became virtual.1,2,3&#x0D; When the first cases started in Porto Alegre, we had already implemented and validated the performance of the PCR for SARS-COV-2, with result until 24 hours. So, we could organize the flow of patients for hospitalizations avoiding admissions of Covid asymptomatic patients. HealthCare’s with any symptoms were kept away from work and quickly tested.&#x0D; We followed the guidance of the Brazilian society of BMT and started to perform only urgent transplants, greatly reducing the number of autologous transplants performed. All patients candidates stem cell transplant were instructed to maintain isolation for 14 days before admission and collected PCR 24 hours before admission. Related and unrelated bone marrow donors underwent clinical screening and PCR testing 24 hours before collection and the marrow was cryopreserved until results what changed our routine marrow infusion and sometime modified the collection from marrow to peripheral Hematopoietic stem cell in order to obtain adequate cellularity.1,2,3&#x0D; Despite all the difficulties and challenges the Covid pandemic imposed upon us, we managed to perform 16 Transplants from March to September, between autologous and allogeneic and we had no cases of covid transmission inside deaths related to COVID until now. All patients who had COVID19 or tested positive to SarsCov2 were outpatients, either from the Day Hospital or the outpatient clinic and had complete resolution of the condition.&#x0D;

Respiratory Syncytial Virus Outbreak in a Veterans Affairs Long-term Care Facility

Background Respiratory syncytial virus (RSV) is increasingly becoming an important cause of respiratory infections in adults, especially those living in long-term care facilities (LTCFs). Seasonal outbreaks peaking from October to April are common. We report an outbreak of RSV involving 2 LTCFs with total capacity of 80 beds in 2019. Methods Retrospective chart review of cases identified with positive RSV infection via DNA polymerase chain reaction (PCR) from January 24 to February 24, 2019, at 2 LTCF units, in close proximity to each other, at Northport Affairs Medical Center. Results Twenty veterans (18 men and 2 women) tested positive for RSV by rapid PCR. The median age was 73 (47–89) years, 85% are Caucasian, and 5 patients had temperature of greater than 100°F (100°F–102.4°F). All had rhinorrhea and 65% had cough. Medical history shows 45% with dementia, 30% with stroke, and 35% with diabetes; 2 patients on hemodialysis; and 2 patients with chronic obstructive pulmonary disease (COPD). Four patients required hospitalization, and 2 of them required admission to intensive care unit. Length of stay ranged from 1 to 9 days. One patient with COPD required mechanical ventilation. One patient with computed tomography finding of airway impaction had antibiotics stopped by infectious diseases consult, yet he developed Clostridium difficile diarrhea. No deaths were observed, and all patients recovered. Aggressive infection control measures were implemented. Conclusions Respiratory syncytial virus is highly infectious and can easily cause an outbreak in an LTCF. Polymerase chain reaction testing was contributory to identify cases rapidly. Rapid PCR results and intensified infection control measures were instrumental to halt the outbreak.

Hospital outbreak caused by linezolid resistant Enterococcus faecium in Upper Austria

BackgroundEnterococcus faecium is part of the human gastrointestinal flora but may act as opportunistic pathogen. Environmental persistence, high colonization capability and diverse intrinsic and acquired resistance mechanisms make it especially successful in nosocomial high-risk settings. In March 2014, an outbreak of Linezolid resistant Enterococcus faecium (LREfm) was observed at the hematooncology department of a tertiary care center in Upper Austria.MethodsWe report on the outbreak investigation together with the whole genome sequencing (WGS)-based typing results including also non-outbreak LREfm and susceptible isolates.ResultsThe 54 investigated isolates could be divided in six clusters based on cgMLST. Cluster one comprised LREfm isolates of genotype ST117 and CT24, which was identified as the causative clone of the outbreak. In addition, the detection of four other clusters comprising isolates originating from hematooncology patients but also at other hospitals, pointed to LREfm transmission between local healthcare facilities. LREfm patients (n = 36) were typically at risk for acquisition of nosocomial pathogens because of immunosuppression, frequent hospitalization and antibiotic therapies. Seven of these 36 patients developed LREfm infection but were successfully treated. After termination of the initial outbreak, sporadic cases occurred despite a bundle of applied outbreak control interventions.ConclusionsWGS proved to be an effective tool to differentiate several LREfm clusters in an outbreak. Active screening for LREfm is important in a high-risk setting such as hematooncology, where multiple introductions are possible and occur despite intensified infection control measures.

Treatment with Saccharomyces boulardii and Escherichia coli Nissle is safe and associated with reduced nosocomial transmission of vanB vancomycin-resistant Enterococcus faecium on an early rehabilitation ward in Germany: a retrospective analysis.

PurposeAccording to the WHO vancomycin-resistant Enterococcus faecium (VRE) belongs to the microorganisms for which new antibiotics are urgently needed. Depending on the type of vancomycin resistance vanA gene VRE is differentiated from vanB VRE and other types. In this retrospective analysis the results of VRE surveillance performed at a German tertiary hospital with approximately 1,200 beds between 2013 and 2017 are shown.Patients and methodsRectal screening swabs were taken at admission and once per week on the early rehabilitation ward of Ingolstadt Hospital (ERWIN) but not at other wards. The number of VRE colonized patients was evaluated by using appropriate computer software (LabCentre, Hybase). The Hybase program was also used to find out the number of Saccharomyces boulardii and multi-susceptible Escherichia coli Nissle in blood cultures of patients at ERWIN. The mechanism of vancomycin resistance was examined by PCR and clonality of VRE strains was analyzed by pulsed-field gel electrophoresis.ResultsBetween 2013 and 2015 the number of VRE increased from 30 to 78 per year whereas in 2016 and 2017 the number declined to 51. Systematic analysis of the laboratory data revealed that this increase was driven by oligoclonal transmission of vanB VRE on ERWIN until August 2016 despite performing intensified infection control measures. However, afterward the number of VRE decreased at ERWIN and subsequently at the other wards. While searching for the reason behind this beneficial development we noticed that at ERWIN, patients treated with antibiotics received two probiotic medications simultaneously (S. boulardii, E. coli Nissle) for the duration of the antibiotic therapy plus an additional 2 days. There was no indication of side effects caused by these microorganisms, particularly no infections.ConclusionApplication of S. boulardii and E. coli Nissle was safe and associated with reduced transmission of VRE from patient to patient at ERWIN. Therefore, in our setting, probiotic treatment of patients receiving antibiotics contributed to the increase of patients’ safety.

Transmission Risk on a Neonatal Intensive Care Unit: Escherichia coli versus Klebsiella pneumoniae.

Isolation precautions required for neonatal intensive care units are part of a bundle with the aim to prevent transmission, colonization, and infection with multidrug-resistant gram-negative pathogens as neonates face an increased risk of mortality and morbidity in case of infection. The following short report describes a transmission of 3MDRGN Klebsiella pneumoniae on a neonatal intensive care unit in a university hospital in Germany. This transmission occurred even though intensified infection control measures were in place, which impressively shows the importance of surveillance, outbreak management, and awareness of contributing factors regarding outbreak situations.

Epidemiological surveillance of multidrug-resistant gram-negative bacteria in a solid organ transplantation department.

We assessed the impact of intensified infection control measures (ICM) on colonization and infection caused by carbapenem-resistant (CR) Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii in a solid organ transplantation (SOT) department. A quasi-experimental methodology was followed. The study was divided into three periods: pre-intervention, intervention with implementation of an ICM bundle including active surveillance program (ASP) and gradually enhanced measures, and post-ASP without ASP. The bundle included active surveillance cultures, contact precautions, hand hygiene, education of health care workers (HCWs), monitoring of compliance, and environmental cleaning. Incidence of colonization and infection caused by CR gram-negative bacteria was recorded. Molecular analysis of CR bacteria was performed for a certain period. During the intervention, incidence of colonization reduced from 19% to 9% (P<.001). The compliance of HCWs with contact precautions and hand hygiene also improved. Monthly incidence of infections caused by these CR bacteria increased from 2.8 to 6.9/1000 bed-days (P<.001). However, this increase did not have such a strong trend after the intervention. Most K.pneumoniae isolates, the commonest pathogen, carried the blaKPC gene. Colonization and infection rates by CR K.pneumoniae, P.aeruginosa, and A.baumannii were high among SOT recipients. In settings where CR gram-negative bacteria are endemic, colonization and infection rates by these bacteria are high among SOT recipients. Implementation of enhanced ICM in all related units of a hospital, although challenging, reduces colonization rates by CR gram-negative bacteria.

Not just a matter of size: a hospital-level risk factor analysis of MRSA bacteraemia in Scotland.

BackgroundWorldwide, there is a wealth of literature examining patient-level risk factors for methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. At the hospital-level it is generally accepted that MRSA bacteraemia is more common in larger hospitals. In Scotland, size does not fully explain all the observed variation among hospitals. The aim of this study was to identify risk factors for the presence and rate of MRSA bacteraemia cases in Scottish mainland hospitals. Specific hypotheses regarding hospital size, type and connectivity were examined.MethodsData from 198 mainland Scottish hospitals (defined as having at least one inpatient per year) were analysed for financial year 2007-08 using logistic regression (Model 1: presence/absence of MRSA bacteraemia) and Poisson regression (Model 2: rate of MRSA bacteraemia). The significance of risk factors representing various measures of hospital size, type and connectivity were investigated.ResultsIn Scotland, size was not the only significant risk factor identified for the presence and rate of MRSA bacteraemia. The probability of a hospital having at least one case of MRSA bacteraemia increased with hospital size only if the hospital exceeded a certain level of connectivity. Higher levels of MRSA bacteraemia were associated with the large, highly connected teaching hospitals with high ratios of patients to domestic staff.ConclusionsA hospital’s level of connectedness within a network may be a better measure of a hospital’s risk of MRSA bacteraemia than size. This result could be used to identify high risk hospitals which would benefit from intensified infection control measures.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1563-6) contains supplementary material, which is available to authorized users.

High prevalence of carbapenem resistance among plasmid-mediated AmpC β-lactamase-producing Klebsiella pneumoniae during outbreaks in liver transplantation units

During a prospective surveillance using PCR for the detection of plasmid-mediated AmpC β-lactamase (pAmpC)-producing Enterobacteriaceae, outbreaks due to pAmpC-producing Klebsiella pneumoniae (pAmpC-Kp) occurred in an adult liver transplantation unit (aLTU) and a paediatric liver transplantation unit (pLTU), with carbapenem-resistant (CR) variants. Between April 2010 and March 2012, a total of 32 patients infected with pAmpC-Kp were found by prospective surveillance using PCR detection at a Japanese university hospital. Multilocus sequence typing, analysis of outer membrane proteins, and detection of carbapenemases were performed. Clinical courses of patients with bloodstream infection (BSI) were reviewed. Of 32 pAmpC-Kp isolates from each patient, 20 (18 from aLTU patients) were DHA-1-producing sequence type 11 (DHA-1-ST11), 9 were CMY-2-ST45/778 (all from pLTU patients) and the other 3 isolates had different sequence types. CR variants were isolated from 8 aLTU patients with DHA-1-ST11 and from 1 pLTU patient with CMY-2-ST45. All of the pAmpC-Kp isolates, including CR variants, were negative for carbapenemases. All of the DHA-1-ST11 and CMY-2-ST45 isolates lacked OmpK35, and seven CR variants also lacked OmpK36. BSIs due to DHA-1-ST11 isolates, including CR variants, occurred in six aLTU patients, four of whom died. The outbreaks were controlled after application of intensified infection control measures. During pAmpC-Kp outbreaks involving 27 liver transplants, CR variants with porin loss developed in nine patients, and DHA-1-ST11 K. pneumoniae caused BSIs with high mortality.

Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in Puerto Rico Associated with a Novel Carbapenemase Variant

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is resistant to almost all antimicrobial agents, and CRKP infections are associated with substantial morbidity and mortality. To describe an outbreak of CRKP in Puerto Rico, determine risk factors for CRKP acquisition, and detail the successful measures taken to control the outbreak. Two case-control studies. A 328-bed tertiary care teaching hospital. Twenty-six CRKP case patients identified during the outbreak period of February through September 2008, 26 randomly selected uninfected control patients, and 26 randomly selected control patients with carbapenem-susceptible K. pneumoniae (CSKP) hospitalized during the same period. We performed active case finding, including retrospective review of the hospital's microbiology database and prospective perirectal surveillance culture sampling in high-risk units. Case patients were compared with each control group while controlling for time at risk. We sequenced the bla(KPC) gene with polymerase chain reaction for 7 outbreak isolates and subtyped these isolates with pulsed-field gel electrophoresis. In matched, multivariable analysis, the presence of wounds (hazard ratio, 19.0 [95% confidence interval {CI}, 2.5-142.0]) was associated with CRKP compared with no K. pneumoniae. Transfer between units (adjusted odds ratio [OR], 7.5 [95% CI, 1.8-31.1]), surgery (adjusted OR, 4.0 [95% CI, 1.0-15.7]), and wounds (adjusted OR, 4.9 [95% CI, 1.1-21.8]) were independent risk factors for CRKP compared to CSKP. A novel K. pneumoniae carbapenemase variant (KPC-8) was present in 5 isolates. Implementation of active surveillance for CRKP colonization and cohorting of CRKP patients rapidly controlled the outbreak. Enhanced surveillance for CRKP colonization and intensified infection control measures that include limiting the physical distribution of patients can reduce CRKP transmission during an outbreak.

Success of an Infection Control Program to Reduce the Spread of Carbapenem-Resistant Klebsiella pneumoniae

To assess the effect of enhanced infection control measures with screening for gastrointestinal colonization on limiting the spread of carbapenem-resistant Klebsiella pneumoniae in a New York City hospital endemic for this pathogen. Retrospective observational study with pre- and postinterventional phases. Beginning in 2006, a comprehensive infection control program was instituted in a 10-bed medical and surgical intensive care unit at a university-based medical center. In addition to being placed in contact isolation, all patients colonized or infected with carbapenem-resistant gram-negative bacilli, vancomycin-resistant Enterococcus, or methicillin-resistant Staphylococcus aureus were cohorted to one end of the unit. Improved decontamination of hands and environmental surfaces was encouraged. In addition, routine rectal surveillance cultures were screened for the presence of carbapenem-resistant pathogens. The number of patients per quarter with clinical cultures positive for carbapenem-resistant K. pneumoniae was compared during the approximately 2-year periods before and after the intervention. The mean number (+/-SD) of new patients per 1,000 patient-days per quarter with cultures yielding carbapenem-resistant K. pneumoniae decreased from 9.7 +/- 2.2 before the intervention to 3.7 +/- 1.6 after the intervention (P < .001). There was no change in the mean number of patient-days or the mean number of patients per quarter with cultures yielding methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, or carbapenem-resistant Acinetobacter baumannii or Pseudomonas aeruginosa after the intervention. There was no association between antibiotic usage patterns and carbapenem-resistant K. pneumoniae. The comprehensive intervention that combined intensified infection control measures with routine rectal surveillance cultures was helpful in reducing the incidence of carbapenem-resistant K. pneumoniae in an intensive care unit where strains producing the carbapenemase KPC were endemic.

Clustering of enterococcal infections in a general intensive care unit

This is a retrospective study comparing patients’ characteristics, antibiotic consumption and environmental contamination before the impact of a new regimen of intensified infection control measures in a general intensive care unit (ICU) at a university-affiliated tertiary-care teaching hospital. The new regimen consisted of (1) reorganization of patient rooms (2) improved hygienic measures including strict hygiene barrier nursing (3) more isolated patient care and (4) more restrictive use of antibiotics. The regimen was introduced after a cluster of enterococcal infections. All patients admitted to the ICU from 1 March 1995 to 28 february 1997 were included. A study period of 12 months after reorganization of the ward was compared with the 12 months immediately before it. The antibiotic consumption, the individual patient's severity of disease (APACHE score), and the extent of therapeutic interventions (TISS score) were recorded. Enterococci were typed biochemically, antibiograms were established and the relation between the isolates was investigated with pulsed-field gel electrophoresis. The bacteriological results and the patient data suggested a hospital-acquired spread as the cause of the ICU enterococcal outbreak. After implementation of the new regimen, we observed a reduction in the rate of enterococcal bloodstream infections from 3.1 to 1.8%. The consumption of antibiotics fell from 6.11 to 4.24 defined daily doses per patient. The introduction of strict hygiene and barrier nursing, more restrictive use of antibiotics, isolation of infected patients, thorough cleaning and disinfection of the unit was followed by an absence of enterococcal infection clustering and reduction in incidence of enterococcal bacteraemia. We were not able to determine whether the reduction in antibiotic consumption was due to the intervention programme.